Provider Demographics
NPI:1063662229
Name:SW VA PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:SW VA PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:LUDGATE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:276-628-5752
Mailing Address - Street 1:PO BOX 245
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24212-0245
Mailing Address - Country:US
Mailing Address - Phone:276-628-5752
Mailing Address - Fax:
Practice Address - Street 1:361B FALLS DR NW
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-8093
Practice Address - Country:US
Practice Address - Phone:276-628-5752
Practice Address - Fax:276-628-5190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002165101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007703171Medicaid